SUPPORTING DOCUMENTATION FINDINGS OP THE SENATE SPECIAL COMMITTEE ON AGING THE MEDICARE SICKER-QUICKER PHENOMENON

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Gilbert O’Connor’
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1 SUPPORTING DOCUMENTATION FINDINGS OP THE SENATE SPECIAL COMMITTEE ON AGING THE MEDICARE SICKER-QUICKER PHENOMENON A. SURVEYS OP HEALTH PROFESSIONALS: EFFECT OP PPS ON QUALITY OF CARE American Medical Association Membership Survey, 8/31/85 66 percent of the 389 doctors who responded to the survey felt that quality of care has suffered under PPS. 43 percent responded that they felt under some pressure to discharge patients sooner from hospitals. Most of the doctors responding were chiefs of medical staffs who had incorporated staff doctors' views. American Society of Internal Medicine Membership Survey, 10/85 More than 42 percent of the 246 internists responding to the survey felt under some pressure to discharge patients earlier from hospitals, sometimes earlier than they felt was medically necessary. 42 percent felt that quality of care had suffered under the prospective payment system and 41 percent said that DRGs do not account for the degree of patient illness. University of Tennessee Study, 10/24/83 45 percent of the doctors responding to this survey of health care providers in 10 eastern Tennessee counties felt that quality of care had declined under the prospective payment system. 47 percent of hospital administrators and 50 percent of nursing home administrators agreed. 50 percent of all physicians, hospital administrators, and nursing home administrators also felt that the DRG categories are "too rigid" or "too simplistic."

2 State University of New York Surveys of Discharge Planners, December 1982 and August hospital-based discharge planners responded to both surveys. Only 15 percent of patients receive follow-up attention from discharge planners in the second survey post-pps versus 32 percent before implementation of the prospective payment system. 56 percent of discharge planners report increased workload since PPS, but 80 of those have not had an increase in their staffing to cope with the increased workload. B. PPS IMPACT ON HOSPITAL QUALITY OP CARE 1985 Published HCFA Data The average length of stay for Medicare patients post-pps dropped 20 percent, or an average of 2 days per stay. This reflects an intended goal of the Medicare prospective payment system and is mirrored in average lengths of stay for non-medicare patients as well. PPS Monitoring Committee Memo to HCFA Administrator, Sept ,576 cases of suspected premature discharge were referred by the PROs to HCPA for follow-up. These figures are as of July 31» Because of a lack of HCFA instructions, "premature discharge" is poorly defined and the memo ignores many quality problems. Staff Study of Hundreds of PRO Monthly Reports to HCFA Premature discharge reporting is hit or miss: 1/3 of PROs account for 90 percent of all reported premature discharges. One-third of the PROs had reported none by mid DHHS Office of Inspector General "Early Alert" Memo to HCFA, November 25, f This memo points out "serious deficiencies" in procedures used by HCFA and the PROs to deal with premature discharge. In 43 percent of identified poor quality cases, the PROs took no action.

3 Northwest Regional Educational Laboratory Study, November 1985 Patients in DRGs 89 (simple pneumonia/pleurisy) and DRG 127 (heart failure with shock) have shorter length of stay and are more dependent at discharge under PPS than they were prior to PPS. These are the 3rd and 4th most common DRG discharges to nursing homes. Johns-Hopkins Study, published in New England Journal of Medicine, July 4, 1983 DRGs over and underpay for the hospital cost of caring for a patient. DRGs without a severity of illness adjustment account for only 30 to 40 percent of the variation in cost of care of hospital patients. With severity of illness adjustment, DRGs account for over 60 percent of this variation and are much better indicators of the true cost of patient care. HCPA funded this study of severity of illness. C. PPS IMPACT ON POST-HOSPITAL QUALITY OP CARE AND ACCESS TO CARE PPS Monitoring Committee Report to HCFA Administrator, September 1983 Pound that patients are leaving hospitals more in need of formal nursing care than before PPS. 35 percent increase in the proportion of hospital patients discharged to SNF and home health since PPS implementation began. Southwest Long Term Care Gerontology Center Survey of Area Agencies on Aging, July 30, area agencies on aging throughout the U.S. were surveyed to analyze the effect of PPS on community caregivers. Since PPS began, area agencies on aging have experienced a 365 percent increase in the need for case management services, a 196 percent increase in the need for in-home skilled nursing care, and a 63 percent increase in the need for more personal care. Further, 30 percent of AAAs say there is too little time for good discharge planning, 22 percent say home health care is not always available for patients who need it, and 18 percent have found that skilled nursing beds often are not available for patients who need that care.

4 Testimony of Barbara Jones, RN, County Home Health Coordinator from North Carolina, Before the Senate Special Committee on Aging, September 26, 1983 Barbara Jones testified that one county in North Carolina, experienced a 76 to 111 percent increase in heavy care home health patients. There was a 43 percent increase in the number of home health patients in that county since PPS. As a result, the county health department was forced to cut back its services to children in order to meet the increased home health need of Medicare patients. Michigan Association of Area Agencies on Aging, April 1983 Reported a 129 percent increase in the number of home delivered meals in one county since 1983«There are waiting lists for home meals and supportive services across the state. This study cites the lack of federal attention to the increased need for home care due to PPS. Northwest Oregon Health Systems Agency Study, November nursing homes were studied and surveyed in Portland, Oregon. This study points out that nursing homes are attempting to care for sicker patients at the same time that HCFA is attempting to limit patient access to the Medicare SNF benefit. Under PPS, 21 percent more nursing home patients died in nursing homes, nursing homes had to hire more registered nurses to care for the more severely ill patients being discharged to nursing homes, and yet fewer patients' care was paid for by Medicare. Testimony of John Mitchell Rutoskey, Administrator of a Skilled Nursing Facility in Birmingham, Alabama, Before the Senate Aging Committee, October 24, 1983 Mr. Rutoskey testified that his facility experienced a 270 percent increase in Medicare patient days after PPS and that his facility was unable to accept all those in need due to Medicare reimbursement limitations. He also pointed out the inconsistency in HCFA administration of the Medicare SNF benefit.

5 Testimony of Ray Cogan, M.D., Medical Director of the Albert Einstein Medical Center, Philadelphia, Pennsylvania, October 24, 1983 Dr. Cogan testified that his skilled nursing facility has seen as much as a 60 percent denial rate for Medicare SNP benefits. The number of Medicare patients being served at the facility has fallen from 100 to 35, due to the limit being placed on access to Medicare skilled nursing care. Eastern Washington State Area Agency on Aging Study, February 1985 This study, which was conducted in the Spokane vicinity, cites the stress on families due to PPS. There has been a 27 percent increase in need for home health care, and increased need for more weekend and after hours nursing care.

Innovation and Diagnosis Related Groups (DRGs)

Innovation and Diagnosis Related Groups (DRGs) Kenneth R. White, PhD, FACHE Professor of Health Administration Department of Health Administration Virginia Commonwealth University Richmond, Virginia 23298